The presentation of genital injuries and emergencies in pediatric girls can be misleading. While a straddle injury may present with excessive bleeding yet require only conservative management, an impalement injury may present with no external findings yet require extensive surgery. This issue describes the workup and management of common traumatic genital injuries and nontraumatic genital emergencies in pediatric girls. You will learn:

• Typical presentations of a straddle injury, hematoma, impalement/penetrating injury, imperforate hymen, and urethral prolapse in pediatric girls
• Key questions to ask during the history
• Recommended patient positions and examination techniques to use during the physical examination
• How to determine when interventions are needed and what types of interventions are recommended

Abstract

The presentation of genital injuries and emergencies in pediatric girls can sometimes be misleading. A traumatic injury with excessive bleeding may be a straddle injury that requires only conservative management, while a penetrating injury may have no recognizable signs or symptoms but require extensive surgery. This issue reviews the most common traumatic genital injuries in girls presenting to the emergency department, including straddle injuries, hematomas, and impalement injuries. Nontraumatic emergencies, including hematocolpos and urethral prolapse, are also discussed. Evidence-based recommendations are presented for identifying and managing these common genital injuries and emergencies in pediatric girls.

Case Presentations

A 15-year-old adolescent girl is brought into the ED by her mother for severe abdominal and pelvic pain with dysuria. The patient is otherwise healthy, with no significant past medical history. She is not sexually active and denies any trauma. Upon questioning, the patient states that she has had cyclical abdominal pain over the past year and a half, which typically lasts 2 to 3 days, and then self resolves. She has not yet started her menses. This is the first time that the pain has been 10/10 in severity, and she has new urinary urgency, with inability to fully empty her bladder. On physical examination, she is Tanner stage V for breast and pubic hair development, her abdomen is soft with no palpable mass, and she has no costovertebral angle tenderness. On visual inspection of her perineum, she is noted to have a large, bulging purplish mass in her vaginal area with a small leak of blood. Are there any laboratory tests that you should order? What imaging—if any—would be the best choice for confirming the diagnosis? Should you try to release the pressure and evacuate the blood?

Your next patient is a 3-year-old girl who has come in for fever. Two days prior, her brother had injured her with a coat hanger while playing “swords.” According to the patient’s brother, the coat hanger had gone into her “bottom,” but he removed it. Since she had no bleeding or obvious injury, they thought it was okay not tell their mother. During the physical examination, the girl has no abdominal tenderness with palpation and no bloody drainage on limited visual rectal examination. You begin to consider how you should manage this patient. Is her fever related to the injury, or is this a viral illness? Would laboratory studies be helpful? What imaging would be best for evaluating her potential injury?

A concerned mother brings her 7-year-old daughter into your ED after noticing the girl's underwear had blood on it. The girl appears to be uncomfortable. The mother states that the girl attends daycare but that the staff of the school said there was no violence or trauma that occurred there. The girl says that no one examined or touched her “private parts.” The girl’s mother states that her daughter had previously been healthy except for a history of asthma with a recurrent cough. The girl says that she has not had any prior vaginal bleeding. You begin to wonder whether the daycare staff is telling the truth. How worried should you be regarding sexual abuse or undisclosed trauma? What conditions can cause this type of bleeding in a young girl?

Introduction

Traumatic genital injuries are rare in girls and can range from minor skin abrasions to severe injuries of the genitourinary tract or pelvic compartment. Physicians at the Leicester Royal Infirmary in the United Kingdom reviewed a retrospective case series of girls aged 0 to 15 years with genital injuries who presented to the emergency department (ED) between 2002 and 2010. Over the 8 years reviewed, there were 181 genital injuries reported. Of these, 76.2% of the patients were discharged without any significant intervention, demonstrating that the majority of genital injuries can be treated conservatively.1 Although some injuries or emergencies may appear to be significant because of the severity of bleeding, most pediatric girls who present to the ED with genital complaints can be treated without surgical intervention.

This issue of Pediatric Emergency Medicine Practice describes the workup and management of common traumatic genital injuries in pediatric girls, including how to determine when interventions are needed and what types of interventions are recommended. Nontraumatic genital concerns including an imperforate hymen and urethral prolapse will also be discussed, as will how to approach the different stages of these diagnoses.

Critical Appraisal of the Literature

A literature search was performed in PubMed using the following search terms: perineal injuries, labial lacerations, hematocolpos, impalement injuries, perineal trauma, female genital and urogenital abnormalities, vulvovaginal complaints, pediatric genital exam abnormalities AND children, child, or pediatrics. 120 articles were reviewed, ranging in publication date from 1980 to the present; however, there were limited data regarding management of these conditions in the ED setting.

The majority of the publications were retrospective reviews and case reports. Gynecologists, surgeons, and emergency physicians published the majority of the case reports and retrospective reviews. Currently, there are few published guidelines based on qualified multicenter research studies.

Risk Management Pitfalls in the Management of Genital Injuries and Emergencies in Pediatric Girls

1. “This young girl has a labial laceration. She should have a surgical consult for immediate repair.”

Not every labial laceration requires surgical intervention. If the bleeding is controlled and the source of bleeding is determined to be external to the vaginal canal, the patient can be treated and given a disposition by the emergency clinician.

3. “This adolescent with hematocolpos already has a small tear in her hymen that is allowing bleeding. We can release the remainder of the blood here in the ED.”

A hymenotomy should never be performed in the ED. Due to the high risk of ascending infection, the procedure needs to be performed in the operating room under aseptic conditions.

4. “Since there are no external signs or symptoms concerning for a serious injury, I don't need to do any further workup on this child who fell on a toy.”

There are many instances in the literature where an impalement injury was missed due to lack of imaging and further investigation. Impalement injuries may be subtle, and if not treated immediately, may lead to peritonitis and bacteremia. At a minimum, further questioning regarding the appearance of the toy is warranted before making this determination.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

Unestrogenized tissues in prepubertal girls can lead to significant bleeding at the time of injury; however, spontaneous hemostasis is generally achieved by the time the medical evaluation is complete.

Children should never be forced into a genitourinary examination position. Having the child sit on a parent’s lap in a supine, frog-leg position can make the examination more comfortable for some children. Anxiolysis or procedural sedation may be required if the child is uncooperative.

Patients with genitourinary emergencies should be evaluated for evidence of urinary obstruction.

Traumatic genitoanal injuries can be classified using an injury severity score. (See Table 2.) Scores of II or greater may warrant specialty consultation.

Determine the most appropriate imaging for children with impalement injuries.

Identify and treat simple and chronic urethral prolapse.

Physician CME Information

Date of Original Release: October 1, 2018. Date of most recent review: September 15, 2018. Termination date: October 1, 2021.

Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.

Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 2 Trauma credits, subject to your state and institutional approval.

ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.

AAP Accreditation: This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per year. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.

AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.

Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.

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